Atlas of Urogynecologic Surgery Tajnoos Yazdany, Donald R Ostergard
Page numbers followed by ‘b’ box; ‘f’ figure; and ‘t’ indicate table respectively.
approach 156
step-by-step techniques 156
types of 119
exploration 39
hysteropexy, different methods of 45
incisions 137
pad 91
repair 119
robotic-assisted procedures 45
Accessory port placement 131f
Accessory trocars 127
Adhesive disease 17
Adnexa 17
Adventia 55, 59
Allis clamps 35, 38, 59, 158, 109, 153, 160, 161f
Allis-Adair clamps 41
placement of 41f
American College of Obstetricians and Gynecologists 3, 66
American Medical Systems 72
American Urogynecologic Society 65
Anal sphincter
external 143, 149f
internal 143, 149f
muscle, anterior 145f
Anal sphincteroplasty 145
step 145, 146, 148
technique 145
Anesthesia care, monitored 80
Anovaginal fistula 143
Antibiotics 3
Anticholinergic medications 95
Anticipated trocar path 66
Antiplatelet medicines 95
Apical compartment 3
Arcus and graft 57f
Arcus tendineus fascia pelvis 56, 57f
Arm placement on arm boards 10f
Aspirin 95
Autologous fascial slings 84
Babcock, using 20
Bartholin's cyst
excision 25
removal of 25f
Bartholin's cystectomy 24, 24f
Bartholin's gland 22, 24, 25
with Word Catheter placement 23
Benign masses, small 17
Bicycle seat area 89
bladder 124
cyst gland 23
endometrial 40
of fistula site 99
and fistula tract exposure 121
deviation using catheter guide 67f
dysfunction 87
erosion 154
extraperitoneal portion 157f
hydrodistention 123
incision 120f
injection depth of 96f
injection pattern 96f
mobilization 77
neck, level of 85, 86f
perforation 69
pressure 123f
repaired several layers 157f
wall repaired in 23 layers 158f
Bleeding sacrum, tips for 140
Blood loss 3
Blood pressure, cuff upside down 12f
Blood transfusion 33
Blunt dissection 56
Body mass index 3, 127
Boney landmarks, locate 92
Boot stirrups 10
positioning in 11
Bottom-up technique 66
Botulinum neurotoxin type A 95
Bowel diseases 143
Bowel dysfunction 87
Bowel preparation 4
Broad-spectrum antibiotics 3
Bulbocavernosus muscle 103
incision 103f
Bulbcavernosus, plication of 61f
Burch urethropexy 76
operative setup 76
Calcium hydroxyapatite 80
Cancers 22, 40, 115
Candy cane 10
stirrups, positioning in 11
Cardinal ligaments 47
Cardiopulmonary status 136
Cautery, use of 138
Cefazolin 3
Central defects, midline plication for 55
Central docking 132, 132f
Cephalad pubic symphysis 66
Cervix, retraction of 46
Channels for drainage 42
Chinese acupuncture points 87
Chromic suture 35f
Chromopertubation 9
Clamp, insinuation of 153f
Clean intermittent
catheterization 83
self-catheterization 153
Clindamycin 3
Clitoral hood reduction 27
Cloacal defect 145f, 146f
CoaptiteTM 81f
Coccygeus-sacrospinous ligament 38f
Coccyx 89f
Colles’ fascia 103
Colpocleisis 40, 45
Colporrhaphy, posterior 60
anterior 17, 18f
posterior 50
Consent process 4
Cooper's ligament 76f, 78
suture passage 78f
Cuff hematomas 21
Cul-de-sac 50, 120f
anterior 46
of Douglas 59
posterior 17, 18f, 45, 46
Cystoscope 83f, 100, 108
sheath 82
Cystoscopy 68f, 69
and closure 78
with hydrodistention 123
Cystourethrography 108
Cystourethroscopy 160
Cytoscopy 35
De novo stress urinary incontinence 55
Dead space, close of 25f
Deep space, closure of 26f
Deep vein thrombosis prevention 4
Delayed-absorbable sutures, use of 105f
Detrusor overactivity 80
Disease, early stage 123
Distal anterior vaginal wall flaps 101f
Distal periurethral fascia flaps 102f
Distal rectovaginal fistula repair 143
capsule 110f
lumen 109, 110f
tissue, trimming of excess 110f
Diverticulectomy 99, 109
Diverticuli 22
Diverticulum 108
correct location for 132
side 132
Dorsal lithotomy supine 76
Double click test 129
Double wedge resection 28f
Dysuria 108
Ectopic ureteroceles 108
Endometrial hyperplasia 40
Endometriotic cysts 22
fascia 33
white fascia 18
Entry, location of 128
Entry, types of 129
closed technique 129
open technique 129
Epidermal inclusion cysts 22
Epidural anesthesia 145
Epinephrine 55
excess 39
reapproximation of 162
Equipment 81
approach 119
location 68
Falciform ligament 131
Fallopian tubes 4
Familiar cancer syndromes 44
Fascia 59, 127
Fascia lata 84
Fascial graft harvested 84f
Fascial incision, close 154
Fascial slings 84
postsurgical considerations 86
surgical technique 84
Fat pad 119f
Female pelvic medicine 4
Fibrin sealant 140
layer using interrupted U-stitches 60f
vagina wall 60f, 62
Figure-of-8 42f
Fistula, closure of 102f
Fistula repairs 143
Fistula tract 116f, 120
incision of 143f
level of 100
Fistula with ureteral stents 118f
inferiorly, mobilization of 104f
rotation of 105f
Flapping splitting technique 116
Fluid collections 21
Fluoroscopy 92
using 92
Foley bulb 138
level of 138f
Foley catheter 40, 109, 111, 117f, 136
bag 9
placement of 40f, 109
Frequency 108
cyst, excision of 23f
duct cysts 22, 108
Gastroepiploic pedicle 119
Genito-labial folds 70f
Gentle blunt dissection 77
Glomerulations 123f
Gluteal artery, inferior 37
Goalpost-like grid 89, 89f
Graft-augmented repair 61, 62f
Graft overlying 161
Hand protection using basic foam padding 12
Hand-extension 17
Hasson technique 129
Heaney clamp 17
Hemostat, use 154
Hemostatic sutures placed 24f
Hereditary nonpolyposis colonic cancer syndrome 44
Hockey stick V 28f
Hydrodissection with lidocaine 62
Hydrodistention 124f
Hypogastric venous plexus 37
Hysterectomy 17, 33, 44, 45, 49f
Hysteropexy with mesh 50
Iliopectineal (Cooper's) ligament 76
Implantable pulse generator 88, 92
Incision, superior aspect of 161
Inject dilute vasopressin 17
Inside to out technique 71
InterStimTM system 88
Interstitial cystitis 95
Intra-abdominal adhesions 37
Intra-abdominal pressure 76
Intravesical mesh 156
Intravesicular injection 95
procedure of 96
Intrinsic sphincter deficiency 80
Ipsilateral shoulder 66, 69
Iris scissorss 25, 109f
Ischemia 99
Ischial spine 38, 38f, 39f, 50, 56
Ischiopubic ramus 70f
anterior 73
Kelly clamp 158, 160, 161f
Labia majora, incision of 119f
Labia minora, labioplasty of 27
preoperative considerations 27
procedure 27
de-epithelialization 28, 29f
fat pad 103f, 104f
incision 159f
Lacerations, chronic 3rd degree 145
Lahey clamp 17
Laparoscopic 11
and robotic surgery 9
port placement 137f
robotic-assisted procedures 45
trocar placement, primary 127
Latzko technique 115, 117f
LeFort partial colpocleisis 40
Leiomyoma 22
removal of 20
Levator ani muscles 33
Lidocaine 55
Linear resection 27, 27f
Lower urinary tract symptoms 66
Low-lithotomy position 12
Lumen single site 133
MacroplastiqueTM 81
Malignancy 99
Manchester 46
procedure 44, 46f, 47f
Marshall-Marchetti-Krantz procedure 76
Marsupialization 24
with incision 24f
Martius flap 116, 119f, 159f
mobilization of 104f
modified 103
Martius graft 109
Mattress sutures, placement of 149f
Mayo scissors 85
McCall's culdoplasty 19, 20f
anterioposterior attachment of 139f
close over 139
complete removal of 154
different types of 136
erosion 153, 140, 161f, 162
exposure requiring partial removal 154
identified 158f
in bladder cystoscopic view of 156f
in bladder, treatment of 156
repairs 55
scarring of 68
Methylene blue injection 95f
Metzenbaum scissors 19f, 56, 66, 88, 143, 154
using 55
Midurethral incision 67f
Mid-urethral sling 4, 65, 65f, 71, 84, 115, 153
Mini-laparotomy 156f
Mini-sling 73
after placement 72f
trocar with mesh 73f
Minimally invasive surgery 3
Minimally invasive technique 47
Miyazaki technique 38
Monofilament absorbable sutures 148
National Hospital Discharge Survey 115
National Surgical Quality Improvement Program 4
Nerve injuries 10
Nerve roots 90
Neurological pain 34
Neuromodulation 87
O'Conor technique 119, 120f
Obese patients 10, 128b
Obliterative vaginal procedures 40
Obstetric trauma 115
Obstetrical anal sphincter injury 145
Obstetrical trauma 99
Obturator canal 72f
Omentum 119
interposition 121
Onabotulinumtoxin A 95, 96
Oophorectomy 17, 20
Open surgery 10
Operating room 88
patient preparation for 3
patient skin preparation 4
surgical decision-making 3
Ophthalmologic consult 10
Optimal patient positioning 9
Optimal trocar placement 127
Outside to in technique 70
Ovarian pedicle 20
Ovaries 4
Overlapping technique two sphincter flaps 149f
Palmer's point 128f, 129
Palms distance 131
Pararectal space, anatomy of 37f
defects 55
dissection 77, 77f
repair 56
tissue 77f
Pedicle with pean clamps 21
Pelvic floor disorders 3
Pelvic inflammatory disease 17
Pelvic organ injury 33
Pelvic organ prolapse 22, 40, 45f
surgery 44t
Pelvic pain, management for 95
Percutaneous nerve stimulation 87
step-by-step techniques 87
Percutaneous tibial nerve stimulation 87
postprocedure considerations 88
procedural tips 88
Pereyra-Raz suture ligature carrier 85
Perineal body 62
loss of 145f
Perineal epithelium 60
Perineal skin 59f, 60f, 62f
Perineorrhaphy 59
completion of 42f
Peritoneal cavity 18
Peritoneal dissection 138
Peritoneal tissue
using delayed absorbable 139
use elevation of 138
Peritoneum, elevation of 138f
Peritoneum over mesh, closure of 139
Periurethral bulking 108
Periurethral fascia 100, 101f, 102
closure of 102
dissection of 110f
Periurethral versus transurethral injection 81
fascia 116
tissues 144f
Permanent suture, using 50
Persistent occiput-posterior position 145
Persistent pain 153
Petechial hemorrhages 123f
Pfannenstiel incision 137
Phantom pass 70
Polydimethylsiloxane 80
Polypropylene 136
Polypropylene sutures 35f
Posterior repair techniques 59
step-by-step 59
Posthysterectomy anterior dissection 140
Postmenopausal bleeding 40
Postvoid dribbling 108
Potential vessel injury 69f
Preoperative assessment and counseling 95
Primiparity 145
Proctoscopy 143
Prolapse 108
recurrent 136
severe 136
surgery, mesh augmentation of 156
Pubic bone 77, 85f
Pubic ramus
inferior 70
level of 154f
Pubic symphysis 66, 69, 103
Pulse generator 91f
Purse-string suture 56
layers of 43f
Radiation therapy 99
Reconstructive surgery 4
Rectal mucosa 144, 144f
edges of 143, 148f
fistula 143
septum 59
Rectus abdominis fascia 84
Rectus fascial graft 84f
Retropubic dissection 76
Retropubic mid-urethral slings 65, 66
trocar placement, bottom to top 67f
Retropubic space 78, 85, 85f
dissection of 77
general entry into 76
Retropubic urethrovesical suspension 76
Robotic 13
arm angles 133f
assisted laparoscopic
hysteropexy 48
trocar placement 131
uses 47
docking 132
fistula repair 121
gynecologic surgery 9
repair of vesicovaginal fistula 121
Sacral anatomy 137f
Sacral colpopexy 136
procedure 136
Sacral dissection 137
Sacral nerve
neuromodulation 88
neuromodulation, surgical technique 88
root plexus 39
roots 37
stimulation 87
Sacral promontory 138
Sacroiliac notch 89
Sacrospinous ligament 37, 37f, 38, 39, 39f
clearing off 38f
fixation 37
suspension 44
using sweeping motion 39f
Sacrum, identifying 140
Saline drop tests 129
Salpingectomy 17, 20
Sensory responses 88
Si configuration
three arms, semilunar 131f
two arms 131f
Si robot port placement 137f
Si surgical platform 131
Sign of
chemosis 10
infection 62
optimal lateral trocar placement 130
Single site port setup 134f
Skene's gland cyst 108
Skin edges, closure of 26f
dissection of 154f
placement 108
tensioned 86f
Society of Urodynamics and Female Urology 123
Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction 65
Sokol technique 121
Space in layers, RP-MUS 23f
Spence procedure 111
Sphincter repair, overlapping 148f
Sphincters with mattress sutures 149f
Squamous epithelium 22
Stab incision 91f
Stress urinary incontinence 80, 84, 108, 115
treatment of 65
Supracervical hysterectomy 136
Suprapubic bladder drainage 157, 157f, 158
Suprapubic catheter placement 122
Suprapubic intraperitoneal approach 119
Surface electrode medial 88
Surgeon ergonomics 12
Surgical considerations
anatomy 127
port placements 127
Surgical factors 3
Surgical planning 3
Suture 34, 102
absorbable 25f, 27, 6062
apical 34
cephalad 77
chromic 35
control and management 150
cut edge 28
delayed absorbable 23f, 35, 41, 42f, 45, 46, 56, 101
full thickness 76
ligate pedicle 20
ligature carrier 85f
mark points 29
monofilament 50
nonabsorbable 85
one 20 Prolene 39
placement of 34, 57f, 77
polyglycolic acid 68
resorbable 27
suspension 77
tensioning 77, 78f,
U-configuration 56f
use one 0-Vicryl 39
USLS 46, 50
uterosacral 35, 36
Suturing techniques 19f
Synthetic suburethral sling 99
Syringes 95
Systemic diseases 9
Techniques for severe and salvage cases 105
Tension-free repair 143
Tined lead placement 90
around fistula tract 144f
beneath mesh 161
interposition 100
Top-down technique 68
Total colpocleisis 42
inside to out 71
mid-urethral sling 69
outside to in 71
bladder drainage 157f
injection technique 82
procedures 44
tape removal 153
Transvesical approach 121
Trendelenburg 136
entry, direct 129
placement 71
in to out, 72f
secondary 130
top to bottom RP-MUS 68f
removal of 134
sites, closure of 134
Tunneling technique 82f
U-flap incision, inverted 158f
approach 161f
on posterior wall 146f
Ultra-lateral repair 56
considerations 127b
precautions 9, 9b
level of 50
obstruction of 122
entrapment 56
injury rate 33
obstruction 33
stent 119
placement 9
Ureteric orifices 99
Ureteroceles 22
Urethra 99
closure of 102
erosion 154
Urethral bulking 80
analgesia 80
anesthesia 80
antibiotics 80
candidates for 80b
injection 83f
operative setup 80
patient counseling 80
postprocedural patient care 82
Urethral calculi 108
Urethral caruncle 108
Urethral diverticulectomy 84
Urethral diverticulum 108
preoperative considerations 108
procedure 109
Urethral instrumentation 108
Urethral ostia, closure of 110
Urethral visualization 100f
Urethralvesical junction 81f
Urethroscope 100
Urethrovaginal fistula 100f
closure 100
repair 99
diagnostic considerations 99
etiologies 99
patient assessment 99
step-by-step technique 100
timing of repair 99
Urinary retention 86, 153
Urinary tract infection 80, 95, 122
US Food and Drug Administration 66
U-shaped stitches 143
large 21
smaller size 19
cervix and corpus 17
morcellation 4
segment 46
size 17
sound 43
suspension procedures 44
Utero-ovarian ligament 18
Uterosacral and cardinal ligaments 33
Uterosacral ligament 33, 45, 48f
bilaterally 46
grasped 35f
left 48
suspension 33, 33f, 44, 45
grasp 34
new apex posthysterectomy 34
placement of sutures 34
surgical technique 34
time of hysterectomy 34
transvaginal 45
Uterosacral sutures placed 35f
Vagina 71
closure of 121
trimming of 57f
Vaginal 10
angles 34
apex 33
grasping 38f
approach, step-by-step techniques 157
channels 43
cuff 34, 35, 38
angles 38
opening 55
cysts 22
edges 121
epithelium 40, 41, 41f, 55, 56f, 59, 62, 69, 154
after anterior repair 58
closure of 20f, 62
determines 55
dissection of 41, 56f
injection of 55
flap technique 115, 117f, 118f
hysterectomy 17, 18f, 34, 44
incision 57, 67f, 86f, 144f
closure of 57f
repair 159f
U-shaped 85f
leiomyomas 108
length 99
mesh 45
complications 115
exposure 153, 154, 160
step-by-step techniques 160
surgical management of 160
use of 45
mucosa 46
segments of 40
muscularis 55
myomectomies 19
packing 111
prolapse, interventions for 3f
repair 115
route 17
shortening 136
sidewall 23
surgery 10
uterosacral ligament suspension 46f
vault prolapse 37
wall 78, 105f, 111f
anterior 160f
area of 41f
defect, posterior 145f
flap 100
anterior 104
dissection of 109f
mobilization of 103
posterior 41f, 59f, 61f
prolapse, anterior 55
repair, anterior 55
Veress needle 127, 128f, 129
Vesicouterine reflection 19f
Vesicovaginal fistula 99, 115, 119
operative setup 115
Vest over pants 109
Vinci Robotic Surgical System 130
Visual entry, direct 129, 130f
Warfarin 95
Wedge resection 27, 28f
Word catheter placed 23
World Health Organization 115
Xi configuration 133f
Xi robot, using 137
Xi surgical platform 132
Xiphoid process 131
Chapter Notes

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Atlas of Urogynecologic Surgery
Atlas of Urogynecologic Surgery
Editor Tajnoos Yazdany MD FACOG FACS Vice Chair of Education, Department of Obstetrics and Gynecology Chief and Program Director, Female Pelvic Medicine and Reconstructive Surgery Fellowship Associate Professor, David Geffen School of Medicine at UCLA Harbor-UCLA Medical Center Torrance, California, USA Co-Editor Donald R Ostergard MD Professor Emeritus Department of Obstetrics and Gynecology University of California, Irvine Professor-in-Residence UCLA School of Medicine Division of Urogynecology Foreword Donald R Ostergard MD
Jaypee Brothers Medical Publishers (P) Ltd
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© 2020, Jaypee Brothers Medical Publishers
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Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.
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Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity. The CD/DVD-ROM (if any) provided in the sealed envelope with this book is complimentary and free of cost. Not meant for sale .
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Atlas of Urogynecologic Surgery
First Edition: 2020
Printed at
This book is dedicated to my parents whose endless love and support carried me throughout my journey. My accomplished and inspirational sisters. To my loving husband and children who are everything. To all the resident and fellows who have crossed my path–it has been an honor to be part of your journey. And finally, to the patients we serve.
Tajnoos Yazdany MD
Contributors Foreword
In the year 2000, myself, Michael Berman and Bill Yee authored the surgical textbook entitled: Atlas of Gynecologic Surgery which covered all aspects of surgery in gynecology, including, oncology and infertility. This new text covers the urogynecology surgical field in detail. There was no mention of surgical mesh in this earlier text, since it had yet to be introduced for routine use in our surgical practice for repair of pelvic organ prolapse and stress incontinence.
With the introduction of mesh kits for these procedures, gynecologic surgery changed in their favor, since the procedures were dictated in detail by the kit manufacturers, so that any physician regardless of prior surgical experience and training could perform them. An added advantage was that much less time in the operating room was required to place the mesh and physicians were paid more to use mesh. Unfortunately, complications developed after mesh implantation which led the Federal Drug Administration (FDA) to change the classification for pelvic mesh to Class III which requires clinical trials before marketing. More recently the FDA removed all transvaginal mesh kits from the market, since safety and efficacy could not be established in the FDA mandated clinical studies. As a result, with the exception of mesh products meant for abdominal sacral colpopexy, the only mesh kits remaining on the market are those for the treatment of stress urinary incontinence.
Surgical procedures, using native tissue without mesh reinforcement, are now more important to learn to do correctly and efficiently to correct these pelvic floor defects.
The purpose of this text is to focus on urogynecology procedures using native tissue, with the exception of sacral colpopexy. This surgical reference text for the treatment of these conditions is intended for both novice and the experienced surgeons.
Donald R Ostergard MD
This book provides the opportunity to describe procedures in the field of Female Pelvic Medicine and Reconstructive Surgery (FPMRS) that have withstood the test of time. Over the past few years, our field has been subject to numerous controversies and uncertainties regarding what materials to use with federal and local regulations abounding. Our field continues to grow and expand, and comparative studies will further elucidate our understanding. However, the aim of this book is to describe FPMRS procedures that endure through time in a simplified, straight-forward way. I hope readers will enjoy the step-by-step approach of this illustrative book, and continue to help women with pelvic floor disorders (PFDs), one patient at a time. We worked to create a book that provided images, videos and tips that will be useful as trainees perfect their own surgical technique. By no means does this book attempt to be comprehensive in describing every possible way to perform a surgical procedure, but rather techniques, we have found to be efficient, safe and simple. This book is inspired by a patient that I met as a medical student in Honduras, who had waited over 15 years hoping that her complete procidentia would be fixed. Her strength and resilience, helped me understand the toll PFDs have on everyday women.
Tajnoos Yazdany MD
Thanks to Antonia Enriquez for her hard work, dedication and continual support throughout this process. Also we are thankful to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director), Mr MS Mani (Group President), Ms Chetna Malhotra Vohra (Associate Director—Content Strategy), Ms Pooja Bhandari (Production Head), Ms Prerna Bajaj (Development Editor) and the staff of M/S Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, for giving a go-ahead at the very beginning and helping us in every way possible to bring out this book.